(f)   Oral Antibiotics

These are appropriate for patients with substantial numbers of inflamed acne lesions and a few small cysts.

Tetracycline

Tetracycline is the old standby.  Unfortunately, it must be taken 1 hour before eating or 2 hours after eating... a real inconvenience.  Particularly avoid dairy products, iron, and certain antacids.  These interfere with the intestinal absorption of the medication.  Start with 250 mg BID advancing to 250 mg (2) BID if needed.  Side effects to consider are mostly G-I upset and candida vaginitis.  Photosensitivity, while reported, is not a frequent problem.

Whether or not the tetracyclines interfere with the action of oral contraceptives is controversial.  It would be prudent to counsel the patient about this issue and broach the possibility of using a supplemental form of contraception.  The patient who has been previously stable on oral contraceptives should immediately report the new appearance of “spotting” to you.  This potential problem has not been reported with Depo-Provera or Norplant.

Doxycycline

This cousin of tetracycline has the advantage of being able to be taken with food (although not large amounts of dairy products, or mineral supplements).  In fact, taking it on an empty stomach is usually rewarded by G-I upset.  As with all oral antibiotics, vaginal candidiasis is a possibility.  The starting dose is 100 mg per day advancing to 100 mg BID if necessary.

Photosensitivity is a real possibility with this drug.   It should be used with caution to those with significant sunlight exposure.  Although it appears to be allowed by the Naval Aerospace Medical Institute (NAMI) for patients in flight status, a review of the current NAMI, Air Force, or Army flight medicine "allowable medications" list is highly advised.  If in doubt, consult a flight surgeon from the appropriate service.  It is not to be given to those in undersea status or patients in whom large exposures of ultraviolet light are probable.

Minocycline

This is another first cousin of tetracycline that should be taken with food as above.  The side effect spectrum is the same as other tetracyclines.  The risk of photosensitivity is much less than doxycycline.  Headaches and vertigo are a real possibility.  The starting dose is 100 mg per day advancing to 100 mg BID if necessary.  It is contraindicated for aviation or undersea personnel in the Navy.

Erythromycin

This drug is best given on an empty stomach with two glasses of water.  However, if G-I upset occurs, it can be given with a small amount of food, but about 20 percent of the drug will not be absorbed.  Vaginal candidiasis is a possibility.  The starting dose is 250 mg BID, advancing to 500 mg BID if needed.

Beware of multiple drug interactions:  theophylline, digoxin, terfenadine, astemizole, loritidine, coumadin, barbiturates, phenytoin, and carbamazepine.  Check the PDR for details.

(g)  Other Oral Antibiotics

While many other antibiotics have been used in the treatment of acne, their use is probably best initiated by a dermatologist.

(h)  Other Oral Medications

The use of medications to modify the hormonal milieu of acne is probably best left to the specialist.

(i)    Nodulocystic Acne

Use of the medications above should be considered initially.  Oral medications should be used at the higher doses listed above.  If the patient does not respond within 2-3 months, a dermatology consult is appropriate.  The use of isotretinoin (Accutane) may be indicated.

The decision to use isotretinoin is not a casual one and should be left to a dermatologist.  This medication has predictable morbidity and teratogenicity as well as requiring monthly follow-up visits and lab testing (including serum pregnancy testing in women).  The risk of teratogenicity in pregnant women is exceptionally high.

There are also several military-unique considerations to using this medication.  In addition to the predictable dryness and skin fragility, frequent musculoskeletal side effects will further degrade combat readiness of personnel in a large number of military occupations.  The dermatologist is obligated to coordinate this treatment and follow up with the service member's operational primary care provider.  

Written and revised by CAPT Dennis A. Vidmar, MC, USN, Department of Military and Emergency Medicine, and Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, MD (1999).